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APEX > Kidney Liver Endocrine > Flashcards

Kidney Liver Endocrine Flashcards

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1
Q

Serum osmolarity

A

2 [Na+] + (glucose/18) + (BUN/2.8)

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2
Q

Where is ADH produced

A

Supraoptic and paraventricular nuclei of hypothalamus

RELEASED by posterior pituitary gland

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3
Q

Where is angiotensinogen produced?

A

Liver

Renin converts angiotensinogen to Angiotensin I in the systemic circulation

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4
Q

Where is ACE produced?

A

Lung

Converts ang I to ang II

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5
Q

What does AT II do?

A

Stimulates aldosterone release from the zona glomerulosa in the adrenal glands, also a v potent vasoconstrictor

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6
Q

What’s in the medulla?

A

Loops of Henle and collecting ducts

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7
Q

What’s in the cortex?

A

Most of the nephron: glomerulus, Bowmans capsule, proximal and distal tubules

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8
Q

What’s the difference between aldosterone and ADH?

A

Aldosterone controls extracellular fluid volume: Na+ and H20 are reabsorbed together—> ↑ blood volume but doesn’t change osmolarity —> Na+, H20 reabsorption, K+ excretion

ADH (vasopressin) controls plasma osmolarity: H20 is reabsorbed but Na+ is not

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9
Q

What makes the kidney release EPO? What does EPO do after it’s released?

A
  • inadequate 02 delivery to kidney: anemia, hypovolemia, hypoxia
  • stimulates stem cells in bone marrow to produce erythrocytes
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10
Q

What 3 things induce renin release?

A
  • ↓ renal perfusion pressure
  • SNS activation (beta 1)
  • Tubuloglomerular feedback (↓ Na+ and Cl- in distal tubule)
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11
Q

Compare D1 and D2 receptors

A

D1: kidney, splanchnic circulation: gs receptor
D2: presynaptic adrenergic nerve terminal: gi receptor

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12
Q

Renal blood flow

A

650mL/min to each kidney or 20-25% of CO

Afferent → glomerular capillary bed → efferent → peritubular capillary bed

  • Of blood delivered to kidney only 20% filtered at glomerulus (180L/day), call this ultrafiltrate
  • 99% ultrafiltrate reabsorbed after filtration
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13
Q

GFR

A

125mL/min

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14
Q

Filtration fraction

A

20% of renal blood flow (125/650)

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15
Q

Fraction of ultrafiltrate excreted as urine

A

1%

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16
Q

Best estimation of glomerular filtration rate?

A

Creatinine clearance (mL/min)

Normal 95-150mL/min
Mild dysfunction: 50-80
Moderate dysfunction: 10-25
Very f’d up: <10mL/min

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17
Q

GFR calculation

A

(140-age) x (weight in kg) / (serum crt x 72)

For a woman, multiply the answer by 0.85

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18
Q

Coags and renal disease

A

ESRD can have long bleeding time even with normal platelet, PT, PTT values because uremia impairs platelet function

Treatment = desmopressin (replenishes vWF), can do cryo, but has viral risk

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19
Q

How much renal blood flow is filtered at the glomerulus? Where does the rest go?

A 
RBF = 1000-1250mL/min
GFR = 125mL/min or ~20% RBF

So filtration fraction is 20% - means 20% is filtered by the glomerulus and 80% is delivered to peritubular capillaries

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20
Q

MOA of fenoldapam?

A

Selective Da1 receptor antagonist, ↑ RBF

Low dose 0.1-0.2mcg/kg/min renal vasodilator ↑ RBF, GFR, and facilitates sodium excretion without affecting ABP, may offer renal protection during aortic surgery or CPB

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21
Q

Where do carbonic anydrase diuretics work? Use?

A

Proximal tubule (net loss of bicarbonate and sodium, net gain of H+ and Cl-)

used for open angle glaucoma, altitude sickness, central sleep apnea syndrome

SE: metabolic acidosis, hypokalemia

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22
Q

Where do osmotic diuretics work?

A

Sugars that undergo filtration but not reabsorption - proximal tubule is main site and loop of Henle (inhibit water reabsorption)

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23
Q

Where do loop diuretics work and how

A
  • medullary region of the thick portion of ascending loop of Henle
  • poison the Na/K/2Cl transporter so a ton of Na remains in distal tubule causing a ton of dilute urine to be excreted
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24
Q

Location of action of thiazide diuretics

A

Distal tubule (inhibit the Na/Cl transporter there)

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25
Tests of GFR and normal values
BUN 10-20mg/dL Creatinine 0.7-1.5mg/dL Creatinine clearance 110-150mL/min All measure glomerular function
26
Tests of tubular function
Fractional excretion of Na+ (1-3%) Urine osmolarity 65-1400mOsm/L Urine sodium conc 130-260mEq/day Urine spec gravity 1.003-1.030
27
Which hormones are produced by the kidneys?
EPO Calcitriol (1,25[OH]2) = active D3, under control of PTH Prostaglandins - PgE2 and PgI2 vasodilate renal arteries - TxA2 constricts
28
ANS receptors in kidneys?
A2: diuresis B1: renin release
29
Aldosterone: where it’s made, what it does, what triggers release
-Produced in the zone glomerulosa of adrenal gland. ↑ Na/K/ATPase in distal tubules and collecting ducts → facilitates Na+ and H20 absorption and K+ excretion Release triggered by: - RASS stim - Hyponatremia - Hyperkalemia
30
ADH
PRODUCED by hypothalamus, RELEASED by posterior pituitary Controls osmolarity V1 (qi) receptor → potent vasoconstriction V2 (qs) receptor → ↑ aquaporin-2 channels in collecting ducts
31
Lab tests for liver synthetic function
PT, INR, albumin
32
Lab tests for hepatocellular injury
AST, ALT, GST
33
Lab tests for biliary obstruction
Alk phosphatase and GGTP (GGTP is more specific)
34
Pure glucocorticoids
Decadron Betamethasone Triamcinolone (Anti inflammatory + metabolic)
35
Pure mineralocorticoids
Aldosterone (sodium retention, potassium excretion)
36
TX thyroid storm
``` Block synthesis (methimazole, carbimazole, PTU, potassium) Block release (radioactive iodine, potassium iodide) Block T4 → T3 conversion (PTU, propranolol) Beta blocker (propranolol, esmolol) ``` DON’T give aspirin - it helps fever but it can ↑ free fraction T4 and worsen the situation.
37
When is postoperative hypocalcemia usually evident with inadvertent parathyroid removal
24-48 hrs Happens sometimes after thyroidectomy
38
Best steroid for orthostatic hypotension
Fludrocortisone has mineralocorticoid properties 125X cortisol ↑ intravascular volume by promoting salt retention, can help chronic orthostatic hypotension
39
Absolute CI to ECSWL
``` Pregnancy Bleeding risk (coagulopathy or anticoagulation) ```
40
Compelling indicators of renal injury
↑ serum creatinine 100% OU <0.5mL/kg/hr x 12 hrs ↓ GFR >50%
41
Compelling indicators of renal failure
↑ serum creatinine 200% or >4mg/dL ↓ GFR >75% UO <0.3ml/kg/hr x 24 hrs or anuria x 12 hrs
42
TX uremic bleeding
Desmopressin is first line Can also give cryo but ↑ risk viral transmission ↑ bleeding time but other coags normal
43
Hepatic blood flow
30% CO (about 1500mL) Supplied by portal vein and hepatic artery Portal vein=75% flow, 50% 02 Aorta → splanchnic organs → portal vein → liver Hepatic artery=25%flow, 50%02 Aorta → hepatic artery → liver
44
Effects of anesthesia on liver blood flow
Induction of GA can → ↓ liver blood flow 30-50%
45
Synthetic proteins produced by liver
Since the liver produces so many proteins its easier to remember what it DOES NOT produce - immunoglobulins :(produced by humoral immune system) - vWF, factor III (tissue factor) : produced by vascular endothelial cells Factor VIII is made in the liver but it’s made by liver sinusoidal cells and endothelial cells, so it’s NOT made by hepatocytes All other clotting/lysis factors and plasma proteins are made by hepatocytes
46
What is bilirubin an indicator of
Hepatic clearance It’s ↑ in prehepatic, intrahepatic, and cholestatic dysfunction
47
which IA preserves hepatic blood flow the best
Isoflurane
48
Etiologies of cirrhosis
``` ETOH Alpha 1 antitrypsin deficiency Biliary obstruction Chronic hepatitis Hemochromatosis R sided HF Wilson disease (genetic copper accumulation) ```
49
MELD, Child-Pugh
MELD: Bilrubin, INR, serum creatinine Child-Pugh: albumin ascites bilirubin encephalopathy PT
50
CV manifestations of liver disease
``` ↓ SVR, BP ↑ CO ↑ RAAS, ↑ Blood volume ↑ SV02 Diastolic dysfunction ↑ Vd (due to ↓ osmotic pressure) ```
51
Respiratory manifestations of liver disease
``` Restrictive defect ↓ compliance Respiratory alkalosis Hepatopulmonary syndrome Portopulmonary HTN ```
52
TIPS
Shunts blood from portal vein to hepatic vein (outflow vessel) Hemorrhage is a high risk
53
Bile -site, storage, release
Made by hepatocytes, stored by gallbladder, released into duodenum through ampulla of Valter ``` Absorbs DAKE (fat soluble vitamins) Excretory pathway for bilirubin and other products of metabolism Alkalizes duodenum ```
54
Etiologies of SIADH
TBI (most common) Cancer No cancer lung disease Carbamazepine Fluid overloaded dilutional hyponatremia
55
Etiologies of DI
Pituitary surgery (most common) TBI SAH Polyuria Give DDAVP or vasopressin, supportive
56
How does cortisol mitigate the inflammatory cascade
Stabilizes lysosomal membranes and ↓ cytokine release
57
Drug of choice for Addison’s
Prednisone - it’s an analogue of cortisol. Glucocorticoid : mineralocorticoid is 4: 0.8
58
Who should get stress dose steroids
Anyone who has gotten 5->20mg prednisone day for >3 weeks
59
Stress hydrocortisone dosing
``` Minor surgery (hernia, colonoscopy) 25mg IV Moderate surgery (colon, joint, TAH) 50-75mg, taper over 1-2 days Major surgery (CV, thoracic, liver, whipple) 100-150mg IV taper over 1-2 days ```
60
Sulfonylurea oral diabetes drugs
All end in “ide” Avoid if sulfa allergy, carry risk of hypoglycemia
61
When does NPH peak
4-12 hrs 2 hr onset
62
When does regular insulin peak
2-4 hrs 30 min onset
63
Signs of excess glucocorticoid secretion
``` Osteoporosis Muscle weakness Weight gain Mood changes Immunosuppression ```
64
Signs of excess mineralocorticoid activity
HTN Hypokalemia Metabolic alkalosis
65
Etiologies of hypoalbuminemia
``` Infection Nephrotic syndrome Malignancy Burn Malnutrition Liver disease ```

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